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Victorian Integrated Cancer Services Multidisciplinary Team Meeting Statewide Survey 2014Final report

Victorian Integrated Cancer Services Multidisciplinary Team Meeting Statewide Survey 2014Final report

Department of Health

To receive this publication in an accessible format phone (03) 9096 2136, using the National Relay Service 13 36 77 if required, or email [email protected]

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

© State of Victoria, December, 2015

Except where otherwise indicated, the images in this publication show models and illustrative settings only, and do not necessarily depict actual services, facilities or recipients of services. This publication may contain images of deceased Aboriginal and Torres Strait Islander peoples.

Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people. Indigenous is retained when it is part of the title of a report, program or quotation.

ISBN 978-0-7311-6844-6

Available at <www.dhhs.vic.gov.au/cancer>

(1510038)

Contents

Main messages 7

Executive summary 8Introduction 8

Methodology 8

Findings 8

Meeting organisation and infrastructure 9

Recommendations 11

1. Introduction 121.1 Purpose 12

1.2 Background 12

1.3 Monitoring progress towards achieving best practice cancer care 14

1.4 Context 14

1.5 Methodology 15

1.6 Data cleaning 16

2. Characteristics of cancer service multidisciplinary meetings in Victoria 172.1 Overview of MDMs in Victoria 17

2.2 Number of MDMs in Victoria by tumour stream 17

2.3 Number of MDMs in Victoria by ICS 19

2.4 Number of MDMs in Victoria versus incidence of new cancer cases 21

3. Patient-centred clinical decision making 243.1 Who to discuss? 24

3.2 Patient characteristics 25

3.3 Frequency of presentation 27

3.4. Referral processes 28

3.5 Clinical decision-making processes and treatment recommendations 31

3.6 Treatment recommendations 32

3.7 Communication with the patient’s general practitioner 33

4. The multidisciplinary team 354.1 Membership and attendance 35

5. Meeting organisation and infrastructure 365.1 Templates and tools 36

5.2 Frequency and duration 36

5.3 Meeting management processes 39

5.4 Linkages across MDMs 39

5.5 Medicare billing arrangements 40

5.5 Data collection 41

6. Key findings and recommendations 436.1 Key findings 43

6.2 Recommendations 44

References 45

Appendix 1: Multidisciplinary meeting (MDM) Statewide Survey – Victorian Integrated Cancer Services 2014 46

Appendix 2: MDM by Tumour stream by ICS / Health Service 47

Appendix 3: List of Health Services within ICS 51

Appendix 4: Comparison of Identified MDMs by tumour stream 2006-2014 57

Appendix 5: CanNET MDM Dataset 58

Appendix 6: Staging systems used in MDMS, by tumour stream 59

Appendix 7: Recommendations from Multidisciplinary team meetings in Victoria – Monitoring progress towards achieving best practice cancer care 2010-11 61

Main messages

This report presents results from the 2014 Victorian Integrated Cancer Services Multidisciplinary Team Meeting Statewide Survey. This self-report survey, which included a mini audit of multidisciplinary team meeting (MDM) documentation, collected information about the characteristics and functioning of MDMs across the state. Comparison with results from the previous three statewide MDM evaluations indicates that good progress continues to be made in the implementation of statewide multidisciplinary care policy directions.

In 2014 there were 141 MDMs that participated in the survey across 30 health services/organisations.

Of the 141 MDMs surveyed:

• 77 per cent of MDMs were held across metropolitan Melbourne• 61 per cent of patients presented were newly diagnosed (as identified through the mini-audit)• 88 per cent had documented processes and protocols in place for referring patients into meetings• 82 per cent of patients referred from other health services had their treatment recommendations

communicated back to the referring organisation• 83 per cent had a process for identifying patients who required a referral to local support services

outside of the geographical location of the treating organisation• 99 per cent applied clinical practice guidelines and/or local protocols to inform its decision-making

process towards treatment recommendations• 77 per cent always utilised clinical practice guidelines or local protocols• 96 per cent identified using at least one cancer staging system per meeting• 97 per cent documented patient treatment recommendations in patients’ medical records• 62 per cent always communicated treatment recommendations to the patient’s general practitioner.

Although processes and protocols are generally in place to support the organisation and the function of most MDMs, the effectiveness and quality of the MDMs is not able to be determined through this survey.

In 2014, 50 per cent of MDMs were conducted weekly, and 58 per cent reported linkages to other clinicians/health services within and/or across Integrated Cancer Services (ICS) on a regular basis.

Medicare Benefits Schedule (MBS) billing of cases presented at MDMs has increased significantly since the last MDM survey in 2010–11. Responses indicate that in 32 per cent of MDMs, clinicians were utilising MBS billing for MDM case presentations, and 15 per cent of all MDMs were utilising MBS billing to support meeting administration or organisational costs.

Recommendations arising from the survey to support ongoing improvements in MDMs include:

• developing a framework to support the quality, effectiveness and consistency of MDMs, encompassing the areas of core membership, capacity, frequency, timeliness, linkages, communication and use of the latest clinical guidelines and protocols

• reviewing the Cancer Services Performance Indicators methods with a view to assess staging documentation for the haematology and central nervous system tumour streams

• ICS facilitation of MBS billing to support MDM administration costs.

Victorian Integrated Cancer Services Multidisciplinary Team Meeting Statewide Survey 2014

Executive summary

IntroductionThe Victorian Government is committed to improving multidisciplinary care for all Victorian cancer patients. In accordance with policy direction, the Integrated Cancer Services (ICS) have focused on improving the effectiveness of teams, establishing and strengthening multidisciplinary team meetings (MDM) and building effective linkages across and between ICS.

The 2014 Victorian Integrated Cancer Services Multidisciplinary Team Meeting Statewide Survey is the fourth evaluation of cancer MDMs since 2006. Following an initial evaluation in 2006, subsequent evaluations were undertaken in 2008 and 2010–11.

MethodologyThe 2010-11 survey was revised to incorporate findings from a limited literature review in early 2014 and in consultation with the project advisory group and the ICS. The survey (Appendix 1) was undertaken from 11 July 2014, with circulation to all ICS secretariats to complete by 25 August 2014 for all MDMs identified in their region. The survey comprised:

• questions related to MDM processes• a mini audit of the agendas and records of the previous five meetings of each MDM.

The self-reported survey was completed by ICS secretariats and/or the chairs of the MDMs. Responses were submitted by the ICS secretariats via FluidSurveys (an online survey tool).

Data cleaning involved follow-up with ICS secretariats by phone and email where required and data was analysed using Microsoft Excel.

As the survey was administered by the ICS secretariats in their member health services, there is a significantly high proportion of public sector participation.

Findings

Characteristics of cancer service multidisciplinary meetings in VictoriaIn 2014 there were 141 MDMs that participated in the survey (Appendix 2) across 30 health services/organisations (Appendix 3). Some major private cancer services participated in the survey; however, there are additional cancer MDMs known to be held at private health services that did not participate in the survey.

There has been a 22 per cent increase in the number of MDMs since the 2006 survey. The tumour streams with the largest increase in the number of MDMs since 2006 were upper gastrointestinal and central nervous system (each with six new MDMs), haematology/lymphoma (five new MDMs) and endocrine (from zero to four MDMs).

The breast (16 MDMs), lung/thoracic (15 MDMs), haematology/lymphoma and genitourinary tumour streams (14 MDMs each) had the highest number of MDMs. The majority of MDMs (77 per cent) were held in metropolitan areas.


Patient-centred clinical decision makingThe mini-audit demonstrated that 61 per cent of patients discussed were newly diagnosed. Sixty-seven per cent of patients were presented once and 30 per cent of patients were presented two or more times at an individual MDM. In 2014 respondents reported that:

• 88 per cent of MDMs had documented processes and protocols in place for referring patients into meetings

• 59 per cent of MDMs had a documented process for prioritising the discussion of patients• 82 per cent of patients referred from other health services had their treatment recommendations

communicated back to the referring organisation• 83 per cent of the MDMs sampled had an agreed process for identifying patients who required a

referral to local support services outside of the geographical location of the treating organisation• 99 per cent of MDMs applied clinical practice guidelines and/or local protocols to inform its decision-

making process towards treatment recommendations• 77 per cent always utilised clinical practice guidelines or local protocols• 96 per cent of MDMs identified using at least one cancer staging system per meeting• 97 per cent of MDMs in Victoria reported that patient treatment recommendations were documented

in the patient’s medical record• 62 per cent of MDMs always communicated treatment recommendations to the patient’s

general practitioner and 20 per cent sometimes communicated, including where relevant for complex cases.

The multidisciplinary teamIn 2014 team membership data was collected to identify the defined core members (from a list of disciplines) whose attendance was required before MDM case discussions began.

The disciplines identified as core members of MDMs (shown as a percentage across all MDMs) were: medical oncologists, 83 per cent; pathologists and radiation oncologists, 82 per cent each; surgeons, 78 per cent; radiologists, 75 per cent; and nurses, 64 per cent.

Meeting organisation and infrastructure

Templates and toolsIn 2014 the use of templates or tools, such as an agenda, checklist or template, to support MDMs increased to 99 per cent from 36 per cent in 2006. Sixty-nine per cent of MDMs surveyed self-evaluate their activities, undertake clinical audit and review their terms of reference and MDM template/tools. The frequency of these evaluation activities was not reported.

Frequency and durationIn 2014, 49 per cent of MDMs sampled conducted meetings at least once a week, while 35 per cent conducted meetings once a fortnight.

Two-thirds of MDMs are scheduled for a duration of between 31 and 60 minutes, while almost a quarter of all meetings (23 per cent) are scheduled for a duration between 61 and 90 minutes.


Meeting management processesSixty per cent of MDMs reported the use of cancer-specific software to support meeting management/administration. Almost two-thirds of MDMs (65 per cent) use software (cancer-specific MDM software/generic database or a Microsoft program such as Excel or Word) to record patient recommendations and, where there was no electronic process, a copy is manually filed in the patient record.

Linkages across multidisciplinary meetingsLinkages between MDMs and individual healthcare providers support timely treatment planning and enable healthcare providers to create referral pathways for optimal and timely treatment delivery. Linkages have been reported where other health services or individual healthcare providers are identified as participating in more than 75 per cent of MDMs held by an individual multidisciplinary team across the year. Of the 141 MDMs, 82 meetings (58 per cent) reported linkages within and/or across ICS.

From the 82 MDMs with linkages, four categories were identified comprising:

• 67 linkages within any single ICS (63 per cent) • 18 linkages across regional and metropolitan ICS (17 per cent) • 18 linkages across metropolitan ICS only (17 per cent)• three linkages across regional ICS only (3 per cent).

Of these 81 MDMs, 61 had one type of linkage, 18 had two types of linkages and three MDMs had three types of linkages (within own region, regional to regional and metropolitan to regional linkages).

It is recognised that in addition to linkages with regular MDM participants, some MDMs (33 MDMs; 23 per cent) have established linkages with ad hoc participants that engage with MDMs as required.

From the 33 MDMs with ad hoc linkages as required, three categories were identified comprising:

• 28 linkages within any single ICS (57 per cent) • 14 linkages across regional and metropolitan ICS (29 per cent) • six linkages across metropolitan ICS only (12 per cent)• one linkage across regional ICS only (2 per cent).

Almost two-thirds (61 per cent) of the meetings that had linkages with ad hoc participants were hosted by a metropolitan health service, and the remainder (39 per cent) were hosted in regional Victoria.

Of these 33 MDMs, 29 had one type of linkage, seven had two types of linkages and two MDMs had three types of linkages (within own region, metropolitan to regional linkages and metropolitan to metropolitan linkages).

Medicare billing arrangementsOrganisational arrangements to facilitate Medicare Benefit Scheme (MBS) billing were in place for only one MDM in 2010–11. In 2014, responses indicated that in 32 per cent of MDMs, participating clinicians were MBS billing for patients, 56 per cent of MDMs involved clinicians who did not MBS bill while for 12 per cent of MDMs this was not known.

Funds from the MBS billing are used to support administration of the MDM for 15 per cent of all MDMs across five of the nine ICS.


Data collectionIn 2014 the data fields/elements most commonly collected by MDMs were: cancer diagnosis; the lead clinician; clinical and histological cancer staging; and the team members present at each meeting.


RecommendationsThe 2014 Victorian ICS MDM statewide survey evaluation captured a range of data and information to inform progress against multidisciplinary policy, strategic directions, peer organisations and previous survey evaluations and recommendations. The following recommendations are made to help drive improvements in the delivery of multidisciplinary care:

• Develop a quality framework to support the quality, effectiveness and consistency of MDMs. The framework should include and support/facilitate:– attendance by clinicians considered to be core members for each MDM, including supportive and

palliative care healthcare providers– consideration of capacity and demand, timeliness and frequency, efficiency and effectiveness and

appropriate linkages across MDMs– an audit process to assess the quality of MDMs– timely communication of meeting recommendations to general practitioners.

• The methodology for the Cancer Service Performance Indicators program should be reassessed with a view to include the haematology and central nervous system tumour streams when reviewing evidence of documentation of cancer staging as part of the MDM discussion. Findings from the MDM survey show that many MDMs across these tumour streams are utilising appropriate staging systems.

• The ICS secretariats should encourage and support health services to increase the utilisation of appropriate MBS billing as a way of supporting the administration of MDMs.


1. Introduction

1.1 PurposeThe purpose of this report is to: provide statewide, self-reported information on the status of multidisciplinary team meetings (MDMs) in Victoria during 2014; evaluate meetings against a range of policy principles and directions; and provide direction for areas that may require further improvement.

This report will first review the characteristics of cancer service MDMs in Victoria, followed by a review of patient-centred clinical decision-making processes, the composition of the MDM teams, and meeting organisation and infrastructure. The report will conclude with a summary of the main findings and provide key recommendations for consideration by health services, Integrated Cancer Services (ICS) secretariats and policymakers.

Survey questions have been revised since the baseline survey conducted in 2006 and, where possible, comparisons have been made across the results of all four surveys to determine progress since 2006.

1.2 BackgroundCancer care is complex and requires the involvement and careful coordination of multiple disciplines and treatment modalities. Multidisciplinary care is a key component of best practice cancer care, encompassing a collaborative, group decision-making approach that focuses on continuity of care through developing pathways and protocols for the treatment and care of each patient. This may also involve establishing appropriate referral networks, including appropriate referral pathways to meet supportive care needs, and developing team protocols and guidance, including MDM audit mechanisms (Department of Human Services 2006).

There has been a long history of cancer reform in Victoria. The policy document Achieving best practice cancer care: a guide for implementing multidisciplinary care (Department of Human Services 2007) describes three strategic directions for multidisciplinary cancer care:

• creating and supporting effective MDMs• establishing and strengthening multidisciplinary meetings• building effective links across and between ICS MDMs – that is, integrated multidisciplinary care.

The implementation of this policy was further supported by the optimal care pathways (formerly known as the patient management frameworks), which reinforce the requirement for care to be prospectively planned and delivered by a multidisciplinary team for all patients. In 2008, through Victoria’s cancer action plan 2008–11 (VCAP), the Victorian Government set a target to increase the number of newly diagnosed cancer patients who have a documented multidisciplinary care treatment plan by 20 per cent each year from 2009, with the aim of achieving 80 per cent documentation by 2012 (Department of Human Services 2008).

Other recent initiatives, including the new Improving Cancer Outcomes Act 2014 and the 2010 Commonwealth Health and Hospitals Fund grant awarded for a regional MDM software project, provide an opportunity to consolidate and build on the multidisciplinary care achievements to date. The regional MDM software project, in particular, will support the development and implementation of a meeting management system across regional Victoria in 2015–16 for a consistent administration and data collection approach.


1.2.1 Cancer in VictoriaCancer is a major burden of disease for the Victorian community. In 2013, 29,732 people were diagnosed with cancer and 11,009 died from cancer. Cancer incidence is growing by 3.5 per cent per annum (Cancer Council Victoria 2014). Due to the association of increasing age and cancer incidence, 57 per cent of tumours occur in those over 65 years of age.

Cancers of the prostate, lung and melanoma accounted for the majority of new cancers in males. In females, the most common sites were breast, bowel, lung and melanoma. Table 1 provides an overview of cancer incidence by tumour stream and ICS.

Table 1: Cancer incidence by tumour stream and Integrated Cancer Service, 2013

Tumour stream Regional ICSBSWRICS

Regional ICSGICS*

Regional ICSGRICS

Regional ICSHRICS*

Regional ICSLMICS

Metropolitan ICSNEMICS

Metropolitan ICSSMICS

Metropolitan ICSWCMICS

StatewideVictoria

Genitourinary 380 284 352 330 473 1,488 1,761 972 6,040

Colorectal 293 201 229 239 294 958 1,017 695 3,926

Breast 290 208 228 211 263 1,047 1,116 745 4,108

Lung 196 127 180 160 215 614 753 550 2,795

Skin/melanoma 217 140 144 166 170 544 709 327 2,417

Haematological malignancies

204 125 145 148 165 715 743 500 2,745

Gynaecological 94 80 74 67 102 321 379 267 1,384

Head and neck 119 57 65 57 83 262 285 234 1,162

Upper gastrointestinal

173 96 143 154 150 581 662 464 2,423

Central nervous system

46 17 25 17 17 108 120 90 440

Other 182 92 119 106 143 560 591 496 2,289

All malignant tumours

2,194 1,427 1,704 1,655 2,075 7,198 8,136 5,340 29,732

Total 9,055 9,055 9,055 9,055 9,055 20,674 20,674 20,674 29,732Source: Victorian Cancer Registry 5 November 2014

* Cancer incidence relates only to that reported by the Victorian Cancer Registry and does not reflect outflow to other states.

BSWRICS = Barwon-South Western Regional ICS; GRICS = Gippsland Regional ICS; GICS = Grampians ICS; HRICS = Hume Regional ICS; LMICS = Loddon Mallee ICS; NEMICS = North Eastern Melbourne ICS; SMICS = Southern Melbourne ICS; WCMICS = Western and Central Melbourne ICS

1.2.2 Integrated Cancer ServicesIn 2005 an integrated service model for metropolitan and rural cancer services was established through the formation of ICS. The ICS are formal partnerships between health services that form organisational and clinical networks that facilitate planning and service improvement across specific geographic areas to ensure consumer access to high-quality integrated care.


There are eight geographic ICS in Victoria: Barwon-South Western Regional ICS (BSWRICS), Gippsland Regional ICS (GRICS), Grampians ICS (GICS), Hume Regional ICS (HRICS), Loddon Mallee ICS (LMICS), North Eastern Melbourne ICS (NEMICS), Southern Melbourne ICS (SMICS) and Western and Central Melbourne ICS (WCMICS). The Paediatric Integrated Cancer Service (PICS) constitutes a separate population-specific statewide ICS, bringing the total number of ICS in Victoria to nine.

A tumour stream approach to care was concurrently developed to support collaborative approaches to care and service improvement between consumers and health professionals and to reduce unwanted variations in practice.

The ICS secretariats have a key role in supporting cancer policy implementation and, to date, have been instrumental in facilitating improvements in MDMs as well as measurement of progress against the VCAP target.

1.3 Monitoring progress towards achieving best practice cancer care

1.3.1 Baseline In 2006 the first MDM audit was undertaken by each ICS secretariat to provide baseline information about the number of MDMs, their composition, meeting frequency, processes and protocols.

1.3.2 Evaluations The second multidisciplinary survey in 2008 aimed to collect data about MDMs in Victoria two years after the initial survey and 18 months after the introduction of the multidisciplinary care policy. A specific target for multidisciplinary care was set under VCAP. The survey included the questions from the 2006 survey and additional questions sought information about communication, referral and treatment protocols.

In 2010–11 a third survey was undertaken to evaluate and measure progress in MDMs across the state. The information provided by the ICS has enabled measurement of the change in the number of MDMs across tumour streams, MDM membership, team linkages and team processes against the relevant policies.

This report provides results and analysis from the 2014 MDM survey, which is the fourth Victorian self-reported statewide survey. The survey tool has been revised with each survey; however, where possible, these results are compared with the baseline results from the 2006 MDM survey and the subsequent 2008 and 2010–11 surveys.

1.4 ContextVictoria’s model for multidisciplinary care incorporates the structures established to drive change (the ICS and tumour stream groups) and the models that describe the requirements for optimal delivery of care that is safe, of high quality and consistent with best practice (Department of Human Services 2006)

The 2014 MDM survey aimed to collect responses from all MDM meetings that are held across Victoria to:

• assess Victorian cancer MDM processes against the strategic directions set out in the policy documents– Achieving best practice cancer care: a guide for implementing multidisciplinary care (2007)– Linking cancer care: a guide for implementing coordinated cancer care (2007)

• assess progress against the reported findings of the prior survey and against the VCAP targets• identify opportunities to improve and strengthen MDMs in the future.


1.5 Methodology

1.5.1 Data collectionInformation on MDMs occurring in Victoria was captured in a cross-sectional, self-report survey consisting of 32 questions. These questions were based on the multidisciplinary care policy, the 2006, 2008, 2010–11 surveys, a review of available literature on best practice in MDMs, and consultation with the ICS secretariats and the project advisory group, which comprised of cancer clinicians, health service managers and ICS secretariat staff.

As a result a number of questions from the 2010–11 survey were omitted (relating to patient consent and meeting set-up) and additional questions on quality assurance were included. Similarly to the previous survey, respondents were required to conduct a mini audit of the agendas and records of the previous five meetings for each MDM. This mini audit sought to collect information about the MDMs using data available from the agendas.

The draft survey was tested with one ICS and then refined. A workshop was subsequently held with the ICS secretariats to enable the survey questions and response options to be clarified.

The survey and a covering email were distributed in July 2014 to the ICS secretariats for circulation to the chairpersons of the MDMs in their region. The ICS secretariats completed the surveys in consultation with the chairpersons of the MDMs, who were required to approve and sign off on the completed surveys. Surveys were then submitted to the Department of Health & Human Services by the ICS secretariats via FluidSurveys, a web-based survey tool. The data was summarised and analysed using Microsoft Excel.

1.5.2 MDM definition used for the 2014 surveyRespondents were asked to include MDMs that make treatment decisions. These are defined by the Multidisciplinary meeting toolkit as a deliberate, regular, face-to-face (or videoconference) meeting involving a range of health professionals with expertise in diagnosing and managing cancer with the purpose of facilitating best practice management of all patients with cancer (Department of Human Services 2006). Supportive care meetings were excluded from the survey.

In 2014 the ICS identified and surveyed all MDMs in public health services as well as some larger private health services that regularly participate in ICS activities (Cabrini Health, St John of God Health).

1.5.3 Tumour stream categoriesThe 2014 survey provided respondents with 16 options for tumour stream categories:

• 14 tumour-specific categories • a ‘multiple’ tumour stream category • an ‘other’ category.

For the purposes of this survey, hepatoma was singled out from the upper gastrointestinal (GI) tumour stream to reflect the emerging work focusing on this specific cancer.

As a point of clarification, the upper GI tumour stream includes hepatobiliary and upper GI tumours, the breast tumour stream includes early and advanced breast cancers, while the following tumour pairings are combined and counted as one tumour stream throughout the survey and this report: lymphoma and haematology, head and neck, lung and thoracic, and skin and melanoma. With these exceptions, where two or more tumour streams were discussed in one MDM, these have been represented as ‘multiple’ MDMs in the analysis. Table 2 (in section 2) outlines the tumour streams represented in the multiple tumour stream category.


Adolescent and young adult (AYA) MDMs and palliative care MDMs are reported under the ‘other’ tumour stream. Although paediatrics is similar in this regard, paediatrics is included in the survey as a tumour stream as this follows the methodology of previous surveys.

1.6 Data cleaningData cleaning for respondent errors and omissions was conducted prior to analysis. The data cleaning process was used to overcome any discrepancies and values were altered where necessary by checking directly with the relevant ICS and MDM chairpersons.

Missing or inconsistent data was significant for mini-audit questions 16–20, where ICS were required to audit data from the last five meetings for each MDM. Analyses of data revealed that missing or inconsistent data was highest for questions 18, 18.2 and 18.3 combined (19 per cent of responses). These questions related to identifying patients’ stage of diagnosis (newly diagnosed, disease progression or unconfirmed diagnosis). Data for these questions has been analysed using a lower denominator to exclude missing data.

The data cleaning process highlighted a number of areas in the survey where misinterpretation was common:

• Question 5 of the survey asked whether the MDM discusses all newly diagnosed patients. The intent was to find out whether all of the newly diagnosed cancer patients referred to the relevant health service(s) linked with the MDM were discussed. However, a number of respondents interpreted the question as meaning ‘Does the MDM only submit newly diagnosed patients for discussion?’

• Questions 14 and 31: Question 14 asked whether the patient’s treatment recommendations were documented in their medical record and provided a compulsory multi-choice component to identify the method of documentation. In Question 31 respondents were asked to identify a range of core data elements that the MDM recorded, and by which method. The answers to these two questions were often contradictory.


2. Characteristics of cancer service multidisciplinary meetings in Victoria

2.1 Overview of MDMs in VictoriaThe number of cancer MDMs identified in Victorian health services has risen from 116 in 2006 to 141 in 2014, an increase of 22 per cent. The number of MDMs identified across the state between 2006 and 2010–11 was stable (116–119 MDMs) and has since increased significantly. It is acknowledged that there may be additional MDMs held across the state in public and private health services/organisations that may or may not have any interaction with the ICS secretariats.

2.2 Number of MDMs in Victoria by tumour streamThe breast and lung/thoracic tumour streams had the largest number of identified MDMs in 2014 (16 and 15 respectively from a total of 141 meetings). This was followed by haematology/lymphoma, genitourinary and ‘multiple’ tumour streams (14 meetings each) and upper GI (13 meetings). The tumour streams with the smallest number of MDMs were sarcoma (one meeting) and ‘other’ (one each for AYA and palliative care).

The highest increase in the number of MDMs from 2006 to 2014 was identified across the central nervous system (CNS), upper GI/hepatoma, haematology/lymphoma and endocrine specialties (Appendix 4). All other tumour streams have increased slightly over the four surveys, with the exception of breast, which has stayed the same, and colorectal, which has decreased.

The apparent decrease in the reported number of paediatric MDMs since 2008 reflects the change by the PICS in their definition of what constitutes an MDM. A decision was made by the PICS to exclude MDMs where treatment planning was not the primary intent of the meeting.

Caution is recommended when comparing the number of MDMs with previous surveys because this does not account for the duration or frequency of meetings, which may have altered over time. Figure 1 provides an overview of the number of MDMs surveyed by tumour stream and ICS.


Figure 1: Number of MDMs identified in Victoria in 2014, by tumour stream

Note: ‘Other’ category includes an AYA MDM and a palliative care MDM.

Table 2 provides a breakdown of tumour streams/types discussed in the multiple-tumour stream MDMs.

Figure 1: Number of MDMs identified in Victoria in 2014, by tumour stream (source data)

Tumour stream BSWRICS GICS GRICS HRICS LMICS NEMICS WCMICS SMICS PICSBreast 1 0 0 2 0 4 5 4 0Central nervous system 0 1 0 0 0 1 4 2 0Colorectal 1 1 0 1 0 3 4 2 0Endocrine 1 0 0 0 0 0 2 1 0Multiple 1 3 1 3 3 1 1 1 0Genitourinary 1 0 0 1 1 3 4 4 0Gynaecology 0 0 0 0 0 1 4 1 0Haematology/lymphoma 1 0 0 1 1 4 5 2 0Head and neck 0 0 0 0 0 1 4 2 0Lung/thoracic 1 2 1 1 0 2 4 4 0Sarcoma 0 0 0 0 0 0 1 0 0Skin/melanoma 0 0 0 0 0 1 3 2 0Upper GI 1 1 0 0 0 5 4 2 0Hepatoma 0 0 0 0 0 2 1 1 0Paediatrics 0 0 0 0 0 0 0 0 5Other 0 0 0 0 0 0 2 0 0


Table 2: Breakdown of tumour types discussed in the multiple-tumour stream MDMs in 2014

Tumour streams discussed Host health service/organisation ICS

Unidentified St John of God Hospital, Warrnambool BSWRICS

Unidentified Wimmera Health Care Group GICS

Breast and melanoma Ballarat Health Services GICS

Head and neck and also melanoma and lymphoma if either is proven on pathology

St John of God Hospital, Ballarat GICS

Breast, colorectal, endocrine, skin/melanoma, upper GI

Latrobe Regional Hospital GRICS

Head and neck, sarcoma and skin/melanoma

Border East Hume Cancer Network HRICS

Breast and GI North East Health Wangaratta HRICS

Colorectal and upper GI Border East Hume Cancer Network HRICS

Breast, colorectal, gynaecology, head and neck, lung/thoracic, skin/melanoma and upper GI

Mildura Base Hospital LMICS

Thoracic and upper GI Bendigo Health LMICS

Breast and colorectal Bendigo Health LMICS

Head and neck and thyroid Austin NEMICS

Colorectal and upper GI Peninsula Health SMICS

Upper GI and neuroendocrine Peter MacCallum Cancer Centre WCMICS

2.3 Number of MDMs in Victoria by ICS The Australian Bureau of Statistics estimates the resident population based on census data. Following the 2011 census, the Victorian population was estimated at 5,537,817, comprising 4,169,366 people (75 per cent) living in greater Melbourne, and 1,368,451 people (25 per cent) living across the remainder of the state (regional).

The majority of MDMs are held in metropolitan areas (109 MDMs), representing 77 per cent of the total. This figure includes five MDMs, or 12 per cent, that are specifically for the state’s paediatric population. The regional ICS had fewer MDMs (32 MDMs), representing 23 per cent of the total. Regional MDMs often cover multiple tumour streams. The proportion of MDMs held in regional Victoria is slightly less than the proportion of the population in regional Victoria; however, for subspecialty cancer care, including paediatrics, regional patients are generally referred to metropolitan MDMs.

While the total number of cancer MDMs has increased in Victoria by 22 per cent since 2006, the increase has predominantly occurred in metropolitan Melbourne (51 per cent from 116 to 141). The total number of MDMs across regional ICS has decreased by almost 6 per cent over this same period (decreasing from 34 to 32 MDMs).

Of all the ICS, WCMICS had the most MDMs in 2014 (with 48 meetings or 34 per cent of the state total), followed by NEMICS and SMICS (each with 28 meetings or 20 per cent of the total).


Figure 2 shows the total number of MDM meetings occurring in each ICS in Victoria across the four evaluation time points. Caution is recommended when interpreting this graph because it does not reflect the number of tumour streams per meeting, meeting frequency/duration or administrative efficiencies that may have developed over time, or the survey methods that may impact on MDMs included in the survey sample.

Figure 2: Number of MDMs in Victoria by ICS across evaluation time points (2006, 2008, 2010–11 and 2014)

Figure 2: Number of MDMs in Victoria by ICS across evaluation time points (2006, 2008, 2010–11 and 2014) (source data)

ICS 2006 2008 2010 2014BSWRICS 10 9 8 8GICS 13 7 8 8GRICS 1 2 2 2HRICS 5 9 7 9LMICS 5 2 3 5NEMICS 14 20 27 28SMICS 25 24 18 28WCMICS 30 36 39 48PICS 13 10 5 5


2.4 Number of MDMs in Victoria versus incidence of new cancer cases Figures 3 and 4 illustrate the incidence of new cancer diagnoses in Victoria and the number of MDMs in Victoria as a proportion by each tumour stream. A comparison of the proportion of tumour stream MDMs with the incidence by tumour stream raises some queries about the capacity to plan patients’ treatment through discussion at an MDM. A major limitation in this comparison exercise is that no consideration is given to the frequency or duration of meetings. In addition, the 2014 survey does not capture all MDMs known to be held at private health services across the state.

The data shows that, compared with incidence, there is a lower proportion of MDMs in the genitourinary, colorectal, skin/melanoma and breast tumour streams. Genitourinary MDMs constitute 9.9 per cent of MDMs surveyed; however, genitourinary cancers accounted for 20.3 per cent of new incidence of cancer in 2013. The proportion of genitourinary patients managed in the private sector is unknown. MDM survey responses indicate that 79 per cent of genitourinary MDMs are held in metropolitan Melbourne, only slightly above the population rate. While there is one genitourinary meeting in each of BSWRICS, LMICS and HRICS, there is no genitourinary MDM in either Gippsland or Grampians regions, nor do the multiple tumour stream MDMs indicate that discussion of genitourinary patients occurs (noting that an MDM held by Wimmera Health Care Group has not identified tumour streams). Furthermore, none of the health services within GRICS and GICS are identified as participating in metropolitan genitourinary MDMs.

Further investigation into the capacity of MDMs may be required as the results of the Cancer Services Performance Indicator audit (round 1, 2014) reports that the rate of documented evidence of the MDM recommendations in genitourinary cancer patients’ medical records is 52 per cent.

Similarly, a comparison of incidence proportion of colorectal cancers (13.2 per cent) and colorectal cancer MDMs (8.5 per cent) shows there are proportionally fewer MDMs than expected.

The proportional incidence of skin cancer (8.1 per cent) is almost double the percentage of MDMs (4.3 per cent) held across the state. While melanoma accounts for 95 per cent of all reportable skin cancers (as per 2013 Victorian Cancer Registry Data published in 2014), generally only patients with late-stage melanoma (3 or 4) cancer will be referred to an MDM.

Current Victorian policy requires that 80 per cent of patients with a new cancer diagnosis have their treatment planned via an MDM. Further exploration of the issues of MDM capacity to meet volume demands and criteria for referral to an MDM is required.


Figure 3: Incidence of new cancer cases in Victoria by tumour stream, 2013

Source: Cancer Council Victoria 2014

Figure 3: Incidence of new cancer cases in Victoria by tumour stream, 2013 (source data)

Tumour stream Total new cancer cases in Victoria (2013)Breast 4108Central nervous system 440Colorectal 3927EndocrineGeneralGenitourinary 6041Gynaecology 1384Haematology/lymphoma 2745Head and neck 1162Lung/thoracic 2795PaediatricsSarcomaSkin/melanoma 2418Upper GI 2423HepatomaOther 2289


Figure 4: Percentage of MDMs in Victoria by tumour stream, 2014

Source: Data as per responses from the Victorian Integrated Cancer Services Multidisciplinary Team Meeting Statewide Survey 2014.


Figure 4: Percentage of MDMs in Victoria by tumour stream, 2014 (source data)

Tumour stream No of meetingsBreast 16Central nervous system 8Colorectal 12Endocrine 4Multiple 14Genitourinary 14Gynaecology 6Haematology/lymphoma 14Head and neck 7Lung/thoracic 15Paediatrics 5Sarcoma 1Skin/melanoma 6Upper GI 13Hepatoma 4Other 2


3. Patient-centred clinical decision making

3.1 Who to discuss?The key principle of multidisciplinary care is that all patients will have the opportunity for prospective treatment and care planning by an MDM that reflects the stage of the patient’s disease (Department of Human Services 2007). Prioritisation protocols for MDMs may be required to maximise the number of patients discussed.

The 2014 survey introduced a new question that asked whether or not the MDM had a documented process for prioritising patients for discussion. Results show that the percentage of MDMs with a documented process for prioritising the patients for discussion in 2014 was 59 per cent (Figure 5). Treatment planning processes for patients not discussed at an MDM were not explored through this survey.

Figure 5: Percentage of MDM meetings with documented processes for prioritising patients for discussion, by ICS

Figure 5: Percentage of MDM meetings with documented processes for prioritising patients for discussion, by ICS (source data)

ICS Yes NoBSWRICS 25 75GICS 100 0GRICS 100 0HRICS 100 0LMICS 100 0NEMICS 64 36


SMICS 46 54WCMICS 46 54PICS 80 20

3.2 Patient characteristicsThe 2014 survey gathered information regarding the characteristics of patients discussed in MDMs throughout Victoria. Respondents were requested to review the agendas and records from the last five consecutive meetings for each MDM and then answer questions related to:

• presentation by newly diagnosed, disease progression and treatment intent• confirmation of discussion of diagnosis• frequency of presentation of the patient’s case at the MDM • consideration of supportive care/palliative care needs • referral processes.

Interpretation of the questions incorporated in the mini-audit varied, resulting in missing or inconsistent data for up to 19 per cent of the surveys submitted. There were several reasons for this:

• Patient numbers were not documented by survey respondents to the level of detail required by the survey.

• MDM software data fields for patient characteristics did not always align with survey question categories.

• Some patients were interpreted as fitting into both the newly diagnosed and disease progression categories because, although they were newly diagnosed, their disease was also well advanced (in these instances the patient was excluded from analysis to avoid being counted twice).

• Some patients did not have a new diagnosis or disease progression. For these patients, survey respondents cited that the patient would often have been brought back to the MDM due to treatment complications and/or the need to revise their treatment plan. A separate exercise was undertaken to review a sample of NEMICS MDM medical records to check that these patients could not be categorised as newly diagnosed, and this was verified.

While the data provides a good indication of what is occurring at a statewide level, caution is recommended when interpreting the results from this section because, while some ICS experienced no barriers to data collection, other ICS indicated that the information requested was not specifically and/or consistently recorded, or not easily identifiable from meeting records. For example, in NEMICS MDM software (CANMAP), disease progression is not recorded, and the ‘recurrence’ data field was used instead. Palliative care issues are also not formally collected as defined fields in the CANMAP meeting management software. Therefore, the results reflect the documentation limitations, not the practice necessarily of MDMs. A statewide consensus MDM dataset was developed as part of the CanNET project (Appendix 5), and the ICS agreed to ensure that local datasets matched this statewide dataset. The impending development of the regional MDM software product provides an opportunity for greater consistency of data captured through an MDM.

3.2.1 Disease at presentationThe MDM survey respondents were asked to estimate the proportion of newly diagnosed patients who are discussed at the MDMs. It is reported that almost three-quarters (74 per cent) of all MDMs discuss 76–100 per cent of newly diagnosed patients at their health service.

In addition to estimates of newly diagnosed patients presented at MDMs, the mini-audit of the last five meeting agendas and records of each MDM identified there were 6,294 case presentations over 705 meetings. When adjusted for missing data, the number of presentations of patients that were identified as newly diagnosed, with disease progression or yet to have a malignant diagnosis, reduced to 5,083.


Using the adjusted figure as the denominator, the percentage of patients discussed statewide who are newly diagnosed is 61 per cent. This figure has decreased from 64 per cent reported in 2010–11.

Twenty-six per cent of presentations are of patients with disease progression and 13 per cent of patients who have an unconfirmed diagnosis. It should be noted that the audit data from the PICS MDMs has not been included here because of the misinterpretation of the questions.

Further evidence of the proportion of newly diagnosed patients who have documented evidence of a multidisciplinary team making treatment recommendations is provided through the Cancer Service Performance Indicators audit. In 2014 (round 1 of this audit), 68 per cent of newly diagnosed patients had documented evidence of multidisciplinary team recommendations (Figure 6). This suggests that the mini-audit results are relatively accurate and assist in creating an understanding of the practice of MDMs.

Figure 6: Newly diagnosed patients as a percentage of all patients discussed in MDM survey audit, by ICS

Note: Although PICS did not participate in the audit, all paediatric cancer patients are presented at a PICS MDM.

Figure 6: Newly diagnosed patients as a percentage of all patients discussed in MDM survey audit, by ICS (source data)

ICS PercentageBSWRICS 75GICS 84GRICS 66HRICS 76LMICS 59NEMICS 33SMICS 70WCMICS 38Statewide 61


3.3 Frequency of presentationThe survey’s mini-audit tried to ascertain the frequency or number of times individual patients had been presented at an individual MDM. Survey responses did not take into account previous presentations at other MDMs at the same or other health services across the state. Consequently one patient may be accounted for more than once, either at various tumour stream MDMs or across health services. This also affects interpretation of this question, as the response does not necessarily represent the number of times the patient has been presented at an MDM for a specific tumour.

The mini-audit results indicate that 4,206 (67 per cent) of the total number of patients presented at an MDM were presented once (Figure 7). MDMs in regional areas had a greater number of patients being presented for the first time (80 per cent of patients in regional MDMs compared with 64 per cent of patients in metropolitan MDMs). A higher proportion of patients were presented three or more times in metropolitan MDMs (13 per cent in metropolitan MDMs compared with 5 per cent in regional MDMs). This could be explained by the fact that patients with complex disease or treatment are often managed in tertiary and quaternary metropolitan health services. It is interesting to note that of all ICS, WCMICS had the largest percentage of second and third or more presentations (21 and 20 per cent respectively, see Table 3), which could relate to the many referral pathways for complex care that lead to four of the major health services within this region. Further exploration into the underlying reasons regarding frequency of patient presentation through local clinical audit is encouraged.

Figure 7: Percentage frequency of patient presentation at MDMs as per the mini-audit

Note: The PICS MDM audit data is excluded from this graph.

Figure 7: Percentage frequency of patient presentation at MDMs as per the mini-audit (source data)

Presentation Statewide RICS MICSFirst presentation 67 80 64Second presentation 17 14 18Third presentation or 12 5 13


greaterUnknown presentation 4 0 4

Table 3: Percentage of patients recorded as first, second or third MDM presentation, by ICS

ICS % of patients at the five MDMs that were first presentation

% of patients at the five MDMs that were second presentation

% of patients presented at the five MDMs that were third presentation

% of patients presented at the five MDMs that were an unknown presentation

BSWRICS 78% 15% 7% 3%

GICS 90% 9% 1% 3%

GRICS 66% 23% 4% 3%

HRICS 87% 11% 2% 3%

LMICS 65% 22% 13% 3%

NEMICS 79% 14% 4% 2%

SMICS 71% 17% 7% 2%

WCMICS 53% 21% 20% 2%

Total 66% 17% 12% 2%Note: The PICS MDM audit data is excluded from this table.

3.4. Referral processesIn 2014, 124 MDMs (88 per cent) reported that documented processes and protocols were in place for referring patients to MDMs, and eight MDMs (6 per cent) were currently developing such processes and protocols. This demonstrates an improvement since 2010–11 in which (95 of 117 MDMs or 81 per cent) had referral protocols in place, while 11 of 117 MDMs (9 per cent) were in the process of developing them. The MDMs that did not have documented processes and protocols in place in 2014 were spread across each of the metropolitan ICS (WCMICS × 4, SMICS × 2 and NEMICS × 1) and one each within PICS and GICS. Figure 8 provides further detail about the existence of documented processes and protocols by tumour stream.


Figure 8: Percentage of MDMs that have documented processes and protocols in place, by tumour stream

Figure 8: Percentage of MDMs that have documented processes and protocols in place, by tumour stream (source data)

Tumour stream Yes

%

Currently in development

%

No

%Breast 88 13 0Central nervous system 100 0 0Colorectal 100 0 0Endocrine 75 0 25Multiple 79 0 21Genitourinary 93 0 7Gynaecology 83 0 17Haematology/lymphoma 79 14 7Head and neck 86 0 14Lung/thoracic 93 7 0Paediatrics 80 0 20Sarcoma 100 0 0Skin/melanoma 100 0 0Upper GI 92 8 0Hepatoma 50 50 0Other 100 0 0


3.4.1 Referrals from other health servicesPatients are often referred to other health services for specialist treatment. Survey results indicate that treatment recommendations were communicated by 82 per cent of MDMs back to the patient’s referring health service. This result is double what was reported in 2010 and reflects a positive move to increase sharing of information between healthcare providers.

3.4.2 Recommendations for referral or direct referral on supportive care and palliative care needs

In addition to asking whether the MDM functions to make recommendations or direct referrals on the patient’s medical treatment plan, the 2014 survey sought to capture information on referrals to meet patients’ supportive and palliative care needs. Responses indicated that 98 per cent of MDMs operated to make recommendations for a medical treatment plan, 66 per cent of MDMs facilitated recommendations for referrals or direct referrals for patient supportive care needs and 85 per cent of MDMs facilitated recommendations for referrals or direct referrals for palliative care needs.

Results from the survey’s mini-audit showed that the 16 per cent of patients had their supportive care needs documented, while 7 per cent of patients had their palliative care needs documented at an MDM. These results do not concur with the assertions made earlier, which suggests that the intent to support referrals that address patients’ supportive and palliative care needs is not evidenced through the documentation. This raises the question of what other processes are in place to meet the supportive and palliative care needs of patients if the MDM does not routinely make the appropriate referrals.

It should be noted that separate supportive care meetings are held by some cancer services, and multidisciplinary palliative care meetings are also known to exist. These types of meetings were excluded in this survey, although one palliative care meeting was identified in the ‘other’ category.

3.4.3 Referrals to local support services outside the geographical location of the treatment organisation

Respondents were asked to indicate whether a process existed at the MDM for identifying patients who required a referral to local support services outside of the geographical location of the treatment organisation (closer to the patient’s home). Eighty-three per cent of the MDMs responded that there is a process to support this intent (Figure 9). Local evaluation may assist in understanding these processes and outcomes further.


Figure 9: Percentage of MDMs that have a process for identifying patients who need a referral to local support services outside of the geographical location of the treatment organisation, by ICS

Figure 9: Percentage of MDMs that have a process for identifying patients who need a referral to local support services outside of the geographical location of the treatment organisation, by ICS (source data)

ICS Yes NoBSWRICS 75 25GICS 13 88GRICS 100 0HRICS 100 0LMICS 100 0NEMICS 86 14SMICS 89 11WCMICS 83 17PICS 100 0

3.5 Clinical decision-making processes and treatment recommendations

3.5.1. Clinical practice guidelines and/or evidence-based treatment protocolsA key policy principle for multidisciplinary care in Victoria is that treatment protocols and multidisciplinary team recommendations are in line with current best practice, including all dimensions of quality, clinical practice guidelines, research and, where these are not available, currently accepted approaches to treatment. The 2014 survey results demonstrate that:

• 77 per cent of MDMs always utilise current published guidelines/local protocols to inform their decision-making process towards treatment recommendations (this has increased from 48 per cent reported in 2010–11)


• 11 per cent of MDMs sometimes utilise current published guidelines/local protocols to inform their decision-making process towards treatment recommendations

• 11 per cent of MDMs utilise current published guidelines/local protocols to inform their decision-making process towards treatment recommendations where relevant for complex cases

• 1 per cent of MDMs never utilise current published guidelines/local protocols to inform their decision-making process towards treatment recommendations.

There is a commonly held view that often the latest evidence in cancer treatment, especially for those patients who present with complex disease, is prescribed before clinical guidelines are published and local protocols are developed. For this reason, the interpretation of the above results should be regarded with caution.

eviQ Cancer Treatments Online is a national resource that provides evidence-based information to support health professionals in the delivery of cancer treatments. eviQ is supported by the Victorian Government and clinical sector for developing and disseminating resources. Respondents were asked whether the MDM team referred to eviQ guidelines to inform treatment planning. Results show that 16 per cent of MDMs always refer to eviQ, 18 per cent sometimes refer, 11 per cent refer where relevant, 18 per cent refer to other guidelines and 38 per cent never refer to eviQ guidelines.

A key policy principle for multidisciplinary care in Victoria is that MDMs should monitor activities through audit, clinical review and peer review (Department of Human Services 2007). This survey tried to elicit information about the quality and safety practices of the MDM by querying the documentation practices in instances where any clinical decision-making varies from best practice. Eighty-two per cent of MDMs answered ‘Yes’ to this question; however, this response should be treated with caution because the recording of treatment recommendations that are variations from published guidelines could not be identified by the audit. This question could, in the future, be evaluated by an audit process that compares treatment decisions with published guidelines or local protocols.

3.5.2 Staging informationThe requirement to report stage of disease under the Cancer Act 1958 was strengthened through the Cancer Reporting Regulations, July 2013. MDMs are considered an appropriate forum for stage to be captured and documented as part of the treatment planning discussion. Ninety-six per cent of MDMs (135) identified using at least one cancer staging system per meeting. Appendix 6 shows the various staging systems used across each tumour stream MDM.

The Cancer Service Performance Indicators round 1 2014 audit also captures data about the documentation of disease staging as part of the MDM discussion. The methodology, however, currently excludes the CNS and haematology tumour streams for this indicator on the basis that there is no single agreed staging system. In this survey, however, half of the CNS MDMs have reported using American Joint Committee on Cancer (AJCC) version 6 or 7 (TNM), while the remaining meetings refer to World Health Organization guidelines for grading. This survey also identified that 87 per cent of haematology MDMs use a range of staging systems. It is recommended that the methodology for the Cancer Services Performance Indicators is reviewed in light of this finding.

3.6 Treatment recommendationsThe MDM survey asked respondents whether a patient’s treatment recommendations are documented in their medical record and how these are documented (see Table 4). Ninety-seven per cent of MDMs responded that patients’ treatment recommendations are documented. An opportunity exists to create efficiencies and consistency across ICS in the process of recording MDM recommendations in establishing the regional MDM software development project.


Table 4: Percentage of MDMs that document treatment recommendations, by ICS

ICS No

%

Recommendations recorded on manual template and copy placed in patient’s medical record

%

Notation made in patient’s medical record

%

Recommendations recorded in software during MDM and automatically uploaded to electronic medical record

%

Recommendations recorded in software during MDM and then printed and filed in patient’s medical record

%

BSWRICS 88 13

GICS 100

GRICS 100

HRICS 11 89

LMICS 100

NEMICS 11 89

SMICS 7 29 11 4 50

WCMICS 4 23 6 17 50

PICS 20 80

The Cancer Services Performance Indicators round 1 2014 report identified documented evidence of MDM recommendations for 68 per cent of the audit sample of (1,688 records of newly diagnosed patients audited statewide). This falls below the 2014 target of 80 per cent. The ICS audit has shown that only two ICS have met this target. The metropolitan average is 76 per cent and regional average is 56 per cent.

The use of MDM software does not appear to improve rates of documented evidence of MDM recommendations. Ninety-seven per cent of MDMs held across regional ICS and 49 per cent of MDMs across metropolitan ICS (including PICS MDMs) said they use cancer-specific MDM software.

3.7 Communication with the patient’s general practitionerGeneral practitioners (GPs) have an important role in supporting cancer patients, and MDMs should endeavour to communicate treatment recommendations to GPs. Eighty-two per cent of MDMs responded that they communicate treatment recommendations to the patient’s GP (Figure 10). The Cancer Services Performance Indicators audit (round 1 2014) found documented evidence of this for 67 per cent of newly diagnosed patients. The 2014 target is for 100 per cent of cases providing documented evidence of communication of the initial treatment plan to the patient’s GP.


Figure 10: Percentage of MDMs that communicate treatment recommendations to the patient’s general practitioner, by ICS

Figure 10: Percentage of MDMs that communicate treatment recommendations to the patient’s general practitioner, by ICS (source data)

ICS Always

%

Never

%

Sometimes

%

Where relevant for complex cases

%BSWRICS 100 GICS 88 13GRICS 100 HRICS 100 LMICS 80 20 NEMICS 46 25 25 4SMICS 68 7 14 11WCMICS 69 8 13 10PICS 60 20 20


4. The multidisciplinary team

4.1 Membership and attendanceThe Victorian guide Achieving best practice cancer care: a guide for implementing multidisciplinary care (Department of Human Services 2007) (‘the policy’) states that multidisciplinary teams comprise all relevant disciplines required to effectively plan treatment and care for cancer patients from diagnosis to end-of-life care. Team members include diagnostic clinicians, specialist and generalist cancer clinicians, GPs, nurses, allied health professionals and supportive care practitioners including palliative care. Team membership is reflective of the individual needs of patients and the stage of the disease, such as early, recurrent, advanced, palliative or any combination of these stages.

A key principle for multidisciplinary care in Victoria states that all core disciplines regularly attend MDMs. Composition of the core team may vary for each cancer type. Victoria’s optimal care pathways (OCPs, previously known as ‘patient management frameworks’) provide a guide when reviewing or establishing core disciplines for MDMs. See www.cancervic.org.au/for-health-professionals/optimal-care-pathways for more information.

In 2010–11 team membership data was collected by asking chairs to identify defined core members (by discipline) who regularly attended the MDM (at least 75 per cent of the time). Responses to this question were then compared with a list of core disciplines for each tumour stream, adapted from those listed in the OCPs.

In 2014, team membership data was collected to identify the defined core members (from a list of disciplines) who were required to be present before case discussion can occur. The survey responses indicated that 83 per cent of MDMs do not commence without medical oncologist attendance, 82 per cent of MDMs do not commence without pathologist or radiation oncologist attendance, 78 per cent of MDMs do not commence without surgeon attendance, 75 per cent do not commence without radiologist attendance, 64 per cent do not commence without nurse attendance, and 53 per cent of MDMs do not commence without attendance by specialist physicians relevant to the tumour stream(s). Two per cent of MDMs (four meetings at Barwon Health) do not commence without GP attendance.

Supportive care (allied health) membership was only considered as core across 28 per cent of all MDMs that were sampled in the 2014 survey. However, it is noted that nurse coordinators may contribute to supportive care discussion where there is no allied health attendance. Additionally, it is known that separate supportive care MDMs exist, although these are not held for each tumour stream or necessarily at each health service. Supportive care meetings were excluded from the 2014 MDM survey.

Nineteen per cent of MDMs did not commence without the attendance of palliative care representatives, although it is known that separate palliative care MDMs exist and weren’t included in the survey.

The data suggests that MDMs review their core membership and attendance records to ensure adequate representation from the recommended team members across all disciplines, in particular, supportive care professionals. Health services should have processes in place to cover planned (and, where possible, unplanned) absences so that appropriate cover can be organised if possible.

A new benchmark was introduced in 2014 to identify whether MDMs were cancelled if a core medical or surgical specialty was unable to be present. The purpose of this question was to obtain an indication of the degree of commitment to specialty input for MDMs to function most effectively. Results showed that


42 per cent of MDMs reported that they cancelled meetings if medical or surgical specialists were unable to attend.

5. Meeting organisation and infrastructure

5.1 Templates and toolsIn 2014 the use of templates or tools to support MDM meetings, such as an agenda, checklist or template that includes patient demographic and clinical information, increased from a baseline of 36 per cent in 2006 to 91 per cent in 2010–11, to a high of 99 per cent in 2014. Of the MDMs sampled, 69 per cent self-evaluate through activities such as a review of the terms of reference and MDM template/tool, and clinical audit. However, details were not captured through this survey. The revision of the Victorian Multidisciplinary meeting toolkit will assist in enhancing the quality of the templates and tools currently in use.

5.2 Frequency and durationThe frequency and duration of MDMs impacts on the ability to discuss and plan treatment prior to patients beginning treatment. Frequency and duration may be dependent upon the number of patients diagnosed and treated locally in each tumour stream. Figure 11 shows that, in 2014, 49 per cent of MDMs were held weekly (an increase from 45 per cent in 2010–11), and a further 35 per cent of MDMs met at least once a fortnight (36 per cent in 2010–11). The duration of MDMs could not be compared between the two survey periods due to a change in the method of analysis.

Figure 11: Frequency of MDMs by tumour stream, 2014

Note: In the legend ‘other’ relates to frequency that is outside weekly/fortnightly/monthly routine.


Figure 11: Frequency of MDMs by tumour stream, 2014 (source data)

Tumour stream Weekly Fortnightly Monthly Other

Breast 75 19 6 0

Central nervous system 50 0 38 13

Colorectal 33 50 8 8

Endocrine 0 0 75 25

Multiple 29 50 7 14

Genitourinary 50 36 14 0

Gynaecology 67 33 0 0

Haematology/lymphoma 36 64 0 0

Head and neck 57 43 0 0

Lung/thoracic 67 20 7 7

Sarcoma 100 0 0 0

Skin/melanoma 33 33 33 0

Upper GI 31 54 8 8

Hepatoma 50 50 0 0

Paediatrics 100 0 0 0

Other 100 0 0 0

In 2014, 67 per cent of MDMs were scheduled for a duration of between 31 and 60 minutes, and 23 per cent of MDMs were scheduled for between 61 and 90 minutes (Table 5). Nine per cent of meetings were scheduled for 30 minutes or less. Of the meetings scheduled for less than 30 minutes, 38 per cent were weekly and 54 per cent were fortnightly. These MDMs covered seven different tumour streams of breast, CNS, colorectal, gynaecology, haematology/lymphoma, lung/thoracic, upper GI and hepatoma.

Table 5: Scheduled length of MDMs in 2014 by tumour stream

Tumour stream Number of MDMs

0–30 min

%

31–60 min

%

61–90 min

%

91–120 min

%

Breast 16 13 75 13 0

Central nervous system 8 25 63 13 0

Colorectal 12 17 50 33 0

Endocrine 4 0 75 25 0

Multiple 13 0 86 14 0

Genitourinary 14 0 71 21 7

Gynaecology 6 17 33 50 0

Haematology/lymphoma 15 14 64 21 0

Head and neck 7 0 71 29 0


Tumour stream Number of MDMs

0–30 min

%

31–60 min

%

61–90 min

%

91–120 min

%

Lung/thoracic 15 13 67 20 0

Paediatrics 5 0 40 60 0

Sarcoma 1 0 0 100 0

Skin/melanoma 6 0 67 33 0

Upper GI 13 8 83 8 0

Hepatoma 4 20 60 20 0

Other 2 0 100 0 0

According to the mini-audit undertaken as part of the survey, 44 per cent of the patients were presented at a WCMICS MDM (Table 6). Forty per cent of patients were also presented at meetings held at NEMICS and SMICS (20 per cent each). While 70 per cent of cancer incidence in Victoria in 2013 occurred within metropolitan Melbourne, the high percentage of MDM presentations within the three metropolitan ICS represents referral pathways and flow from regional cancer services.

The number of MDMs alone may not provide a true picture of the extent of services or self-sufficiency in each ICS. Factoring in frequency and length of meetings enables a true comparison to be made against incidence and across ICS.

Further analysis of the mini-audit data combined with frequency and duration of meetings over the period of one year gives an approximate picture of MDMs across Victoria and allows for easy comparison across ICS. The total number of presentations over the five meetings audited for each MDM were divided by five to obtain an average number of presentations per meeting. Further calculations were based on the assumption of maximum scheduled meeting time (60 minutes for a scheduled meeting time of 31–60 minutes) and frequency (52/26/12 meetings per year for weekly/fortnightly/monthly meetings respectively). Meeting cancellations or variation in actual meeting time has not been factored in.

This analysis estimates that 5,765 hours of MDMs and 49,789 patient presentations were held across Victoria in 2014 over 52 weeks.

It is interesting to note that when frequency and length of meetings was factored in, the percentage of patients in each ICS estimated to be presented at an MDM was similar to the percentage of patients presented at the last five meetings of each MDM as per the audit results. However, this analysis shows that, for WCMICS, the proportion of meeting hours (38 per cent of total MDM hours) is considerably lower than the estimated patient presentations (47 per cent of all presentations), while for all other ICS the correlating percentage of MDM hours and presentations are similar. This estimate is significant given that 34 per cent of Victoria’s MDMs occur across the WCMICS region.

ICS are encouraged to analyse cancer incidence, MDM type, frequency and duration of meetings to ensure that MDMs are efficient, effective and meet the needs of Victorian cancer patients.


Table 6: Estimated number of presented patients and hours of MDMs, 2014

ICS Total number of patients presented for discussion and recommendn at last five MDMs

% of patients presented at last five MDMs as per audit results

Estimated hours of MDM per year*

Estimated % of MDM hours per year*

Estimated presentns

over 12 months*

Estimated % of presentns over 12 months*

Cancer incidence

% of estimated presentns over 12 months compared with cancer incidence, per ICS

BSWRICS 237 4% 240 4% 1,395 3% 2,194 64%

GICS 231 4% 159 3% 928 2% 1,427 65%

GRICS 71 1% 78 1% 593 1% 1,704 35%

HRICS 297 5% 140 2% 1058 2% 1,655 64%

LMICS 183 3% 234 4% 1243 2% 2,075 60%

NEMICS 1,254 20% 1,196 21% 10,978 22% 7,198 153%

SMICS 1,280 20% 1,211 21% 10,358 21% 8,136 127%

WCMICS 2,741 44% 2,170 38% 23,236 47% 5,340 435%

PICS 338 6%

Total 6,294 100% 5,765 100% 49,708 100% 29,732* Estimation doesn’t factor in actual duration, cancelled meetings or leave periods.

5.3 Meeting management processesSince 2006 there has been an increasing number of MDMs using meeting management software to support the administration of MDMs. Respondents were asked to identify if meeting management software was used by the MDM, and to state the type. Options provided to choose from were cancer-specific MDM software, a generic database (for example, Microsoft Access), Microsoft Word, Microsoft Excel, or other. The survey indicated that 60 per cent of MDMs utilise cancer-specific software.

The 2010 MDM survey benchmark result found that 89 per cent of MDMs in Victoria document patient treatment recommendations in the patient’s medical record. In 2014 this increased to 97 per cent. In addition, the 2014 survey sought to identify how patients’ treatment recommendations were documented in their medical record. In particular, a distinction between the ability of software to automatically upload the treatment recommendation to the patient’s medical record with no manual input (such as scanning or printing) and a combination of software and manual input to file the treatment recommendation in the patient’s medical record was made.

Findings showed that:

• 65 per cent of MDMs used software to record patient recommendations, with a copy manually placed into the patient’s record

• 17 per cent of MDMs used a manual template, with a copy placed in the medical record• 11 per cent of MDMs used software that automatically uploads to an electronic patient record• 4 per cent of MDMs placed a notation in the patient’s medical record.

5.4 Linkages across MDMsThe multidisciplinary care policy provides three strategic directions for improving multidisciplinary care in Victoria. The third strategic direction is about building effective links across and between MDMs. This survey captured information about the linkages occurring between services/clinicians across the state but


did not explore the reasons for the linkages or why/how particular linkages were established or how they were supported (via video/teleconference or other means).

Of the MDMs sampled in 2014 (where participants attended more than 75 per cent of the time), 82 MDMs (58 per cent) reported at least one linkage within and/or across ICS, and 59 MDMs (42 per cent) had no linkages with other health services. Four types of linkages were identified: within own ICS; across regional and metropolitan ICS; across metropolitan ICS; and across regional ICS (Table 7).

In addition to these linkages, 38 MDMs (27 per cent) identified at least one linkage per meeting with other health services as required (on an ad hoc basis).

Table 7: Identified linkages with other health services

Attendance Linkages within own ICS Linkages across regional and metropolitan ICS

Linkages across metropolitan ICS

Linkages across regional ICS

Numberof MDMs

Percentage of all linkages

Number of MDMs


Number of MDMs


Number of MDMs


Participating services attending more than 75 per cent of the time

67 63% 18 17% 18 17s% 3 3%

Participating services/clinicians attending as required

28 57% 14 29% 6 12% 1 2%

5.5 Medicare billing arrangementsIn 2006 the Australian Government introduced Medicare Benefits Schedule (MBS) item numbers to support attendance by specialists at team planning meetings (Wilcoxen et al. 2011). Two MBS item numbers can be claimed for discussions during an MDM held for the purpose of developing a cancer treatment plan: item 871 for a medical practitioner (specialist, consultant physician or GP) to lead an MDM for developing a cancer treatment plan, or item 872 to participate in the meeting as a treating clinician. The schedule fee for item 871 is $71 per patient and can only be claimed by the MDM lead clinician. A minimum of four medical practitioners are required at each MDM to meet eligibility criteria for MBS billing, and there is no limit to the number of medical practitioners who can claim item number 872 (provided that they are part of the patient’s treatment team), which has a schedule fee of $33 per patient.

In 2014, respondents were asked to indicate whether any individual clinicians billed patients presented at the MDM using MBS items. In 2014, responses indicated that in 32 per cent of MDMs, participating clinicians were MBS billing for patients presented. Fifteen per cent of all MDMs used funds from the MBS billing to support administration of the MDM (Figure 12).

It is important to recognise the limitations associated with MBS billing for private patients with cancer presented at MDMs. Allied health practitioners must be present in the MDM to enable billing for the meeting by medical practitioners; however, allied health practitioners are ineligible to claim. Additionally, only discussions longer than 10 minutes per patient are eligible for MBS billing. Audit results show that only 25 per cent of patients were identified as presenting at a private health service or private clinical rooms, and on average just over seven patients were presented for each hour of an MDM.

ICS have been instrumental in the formation, facilitation and formalisation of MDMs across various cancer tumour streams. Regional ICS in particular have been instrumental in establishing cancer MDMs in regional areas and, in many instances, have used ICS funding to coordinate and administer the


MDMs. In metropolitan health services ICS funding has mostly supported the purchase/upgrade of facilities and/or technology, including meeting management software for some MDMs.

Information and communications technology (such as meeting management software) generally requires recurrent funding for licencing and maintenance. Revenue from MBS billing offers a potential funding source for these costs in the future.

Figure 12: Percentage of individual MDMs where individual clinicians are MBS billing patients for case presentation, 2014

Figure 12: Percentage of individual MDMs where individual clinicians are MBS billing patients for case presentation, 2014 (source data)

ICS No Yes Unknown

BSWRICS 13 50 38GICS 25 25 50GRICS 0 50 50HRICS 0 56 44LMICS 60 40 0NEMICS 86 11 4SMICS 50 39 11WCMICS 65 33 2PICS 80 20 0

5.5 Data collectionIn 2014 respondents were asked to indicate what data elements are recorded by the MDM from a list of 13 options, and by what method these are recorded. Patient age, cancer diagnosis, presenting clinician, clinical stage and patient comorbidities were the data fields most commonly recorded by the MDM in 2014 (Figure 13). Cancer diagnosis, presenting (lead) clinician and clinical stage were also most commonly recorded in 2010, although patient age and comorbidities were not included in the 2010 survey.


The MDM provides a unique opportunity to obtain valuable patient data that can be used for quality improvement. The collection of consistently defined data items across tumour streams would be most beneficial. In 2014 a series of stakeholder meetings was held to review and confirm a statewide consensus MDM dataset based on an initial dataset that was completed under the CanNET project in 2012. This consensus dataset will be included in the new meeting management software for regional cancer services, and metropolitan ICS are encouraged to support use of this dataset in MDMs.

Figure 13: Recording of core data elements by method across all MDMs, 2014

Figure 13: Recording of core data elements by method across all MDMs, 2014

ICS No Yes Unknown

BSWRICS 13 50 38GICS 25 25 50GRICS 0 50 50HRICS 0 56 44LMICS 60 40 0NEMICS 86 11 4SMICS 50 39 11WCMICS 65 33 2PICS 80 20 0


6. Key findings and recommendations

6.1 Key findingsSignificant improvements have been made by ICS to address the 13 recommendations from the survey report Multidisciplinary team meetings in Victoria: monitoring progress towards achieving best practice cancer care 2010–11 (Appendix 7). Improvements have been identified across the following areas:

• development of MDMs across particular tumour streams and regions with low numbers of meetings or limited capacity compared with Victorian cancer incidence

• use of criteria for prioritising patients presented at MDMs• increased communication of treatment recommendations to the patient’s GP or referring health service• use of clinical practice guidelines or evidence-based treatment protocols• increase use of staging systems• further development of linkages across MDMs• consideration of MBS funding to support administration of MDMs• implementation of cancer-specific meeting management software across MDMs• development of an MDM dataset.

It should be noted that although there has been an increase in use of staging systems in MDMs, according to the 2014 Cancer Services Performance Indicators audit (round 1 2014) staging has decreased from 79 per cent (full year 2013) to 73 per cent in round 1 2014. It is unclear what effect a full year report will have on 2014 data, and there is still work to be done to achieve the staging target of 100 per cent.

Progress has been made on reviewing of the MDM toolkit, which occurred in 2012 as part of the CanNET Project. Publication of this toolkit is planned for 2015.

Attendance of supportive care (allied health) at MDMs remains low. Representation is encouraged in line with team recommendations in OCPs.

The lead or presenting clinician should discuss the benefits of multidisciplinary care and make the patient aware their health information will be available to the team for the MDM.


6.2 RecommendationsThe 2014 Victorian ICS MDM statewide survey evaluation captured a range of data and information to inform progress against multidisciplinary policy, strategic directions, peer organisations and previous survey evaluations and recommendations. The following recommendations are made to help drive improvements in the delivery of multidisciplinary care:

• Develop a quality framework to support the quality, effectiveness and consistency of MDMs. The framework should include and support/facilitate– attendance by clinicians considered to be core members for each MDM, including supportive and

palliative care healthcare providers– consideration of capacity and demand, timeliness and frequency, efficiency and effectiveness and

appropriate linkages across MDMs– an audit process to assess the quality of MDMs– timely communication of meeting recommendations to GPs.

The methodology for the Cancer Service Performance Indicators program should be reassessed with a view to including the haematology and CNS tumour streams when reviewing evidence of documentation of cancer staging as part of the MDM discussion. Findings from the MDM survey show that many MDMs across these tumour streams are using appropriate staging systems.

The ICS secretariats should encourage and support health services to increase the use of appropriate MBS billing as a way of supporting the administration of MDMs.


References

Department of Human Services 2006 revised 2015 Multidisciplinary meeting toolkit, State Government of Victoria, Melbourne

Department of Human Services 2007 Achieving best practice cancer care: a guide for implementing multidisciplinary care, State Government of Victoria, Melbourne

Department of Human Services 2008 Victoria’s cancer action plan 20108-2011

Thursfield V, et al. 2014 Cancer in Victoria: Statistics & trends 2013, Cancer Council Victoria, Melbourne

Wilcoxen et al. 2011 Multidisciplinary cancer care in Australia: A national audit highlights gaps in care and medico-legal risk for clinicians’, Asia Pacific Journal of Clinical Oncology, 7, 34-40


Appendix 1: Multidisciplinary meeting (MDM) Statewide Survey – Victorian Integrated Cancer Services 2014

Please contact the Department of Health & Human Services on (03) 9096 2136 for an accessible copy of Appendix 1: Multidisciplinary meeting (MDM) Statewide Survey – Victorian Integrated Cancer Services 2014.


Appendix 2: MDM by Tumour stream by ICS / Health Service

RegionalICS / Health Service

Bre

ast

CN

S

Col

orec

tal

Endo

crin

e

Mul

tiple

Gen

itour

inar

y

Gyn

aeco

logy

Hae

mat

olog

y/

lym

phom

a

Hea

d an

d ne

ck

Lung

/tho

raci

c

Paed

iatr

ics

Sarc

oma

Skin

/ mel

anom

a

Upp

er G

I

Hep

atom

a

Oth

er

Tota

l

BSWRICS 1 1 1 1 1 1 1 1 8

Barwon Health 1 1 1 1 1 1 1 7

St John of God Hospital, Warrnambool

1 1

GICS 1 1 3 2 1 8

Ballarat Health Services 1 1 1 3

St John of God Hospital, Ballarat

1 1 1 1 4

Wimmera Health Care Group 1 1

GRICS 1 1 2

Central Gippsland Health Service

1 1

La Trobe Regional Hospital 1 1

HRICS 2 1 3 1 1 1 9

Albury Wodonga Health 1 1

Goulburn Valley Health 1 1 1 3


RegionalICS / Health Service

Bre

ast

CN

S

Col

orec

tal

Endo

crin

e

Mul

tiple

Gen

itour

inar

y

Gyn

aeco

logy

Hae

mat

olog

y/

lym

phom

a

Hea

d an

d ne

ck

Lung

/tho

raci

c

Paed

iatr

ics

Sarc

oma

Skin

/ mel

anom

a

Upp

er G

I

Hep

atom

a

Oth

er

Tota

l

Murray Valley Private Hospital 1 1

North East Health Wangaratta 1 1

University of NSW Rural Clinical School

1 1 1 3

LMICS 3 1 1 5

Bendigo Health 2 1 1 4

Mildura Base Hospital 1 1

REGION TOTAL 3 1 3 1 11 3 3 5 2 32


MetropolitanICS / Health Service

Bre

ast

CN

S

Col

orec

tal

Endo

crin

e

Mul

tiple

Gen

itour

inar

y

Gyn

aeco

logy

Hae

mat

olog

y/

lym

phom

a

Hea

d an

d ne

ck

Lung

/thor

acic

Paed

iatr

ics

Sarc

oma

Skin

/ mel

anom

a

Upp

er G

I

Hep

atom

a

Oth

er

Tota

l

NEMICS 4 1 3 1 3 1 4 1 2 1 5 2 28

Austin 1 1 1 1 1 2 1 1 2 1 12

Eastern Health 2 1 1 1 1 1 1 1 9

Mercy Hospital for Women

1 1

Northern Health 1 1 1 1 2 6

SMICS 4 2 2 1 1 4 1 2 2 4 2 2 1 28

Alfred Health 1 1 1 1 1 1 1 1 1 1 1 11

Cabrini 1 1 1 3

Monash Health 1 1 1 1 1 1 1 1 1 9

Peninsula Health 1 1 1 1 1 5

WCMICS 5 4 4 2 1 4 4 5 4 4 1 3 3 2 2 48

Melbourne Health 2 1 1 1 1 2 1 1 2 1 1 1 15

Peter MacCallum Cancer Centre

1 1 1 1 1 1 1 1 1 1 1 11

Royal Women’s Hospital 2 2

St Vincent’s Health 1 2 1 1 1 1 1 1 1 1 1 12

Western Health 1 1 1 1 1 1 1 1 8

PICS 5 5

Monash Childrens 1 1


MetropolitanICS / Health Service

Bre

ast

CN

S

Col

orec

tal

Endo

crin

e

Mul

tiple

Gen

itour

inar

y

Gyn

aeco

logy

Hae

mat

olog

y/

lym

phom

a

Hea

d an

d ne

ck

Lung

/thor

acic

Paed

iatr

ics

Sarc

oma

Skin

/ mel

anom

a

Upp

er G

I

Hep

atom

a

Oth

er

Tota

l

Hospital

Peter MacCallum Cancer Centre

1 1

Royal Children’s 3 3

METROPOLITAN TOTAL 13 7 9 3 3 11 6 11 7 10 5 1 6 11 4 2 109

VICTORIAN TOTAL 16 8 12 4 14 14 6 14 7 15 5 1 6 12 5 2 141


Appendix 3: List of Health Services within ICS

Barwon South Western RICSName

Barwon South Western RICSHospital type

Balmoral Bush Nursing Centre Public

Barwon Health* Public

Bellarine Community Health Public

Casterton Memorial Hospital Public

Colac Area Health Public

Geelong Private Hospital Private

Heywood Rural Health Public

Hesse Rural Health Service Public

Lorne Community Hospital Public

Moyne Health Services Public

Otway Health and Community Services Public

Portland District Health Public

St John of God Health Care Geelong Private

St John of God Health Care Warrnambool* Private

South West Healthcare Public

South West Healthcare Public

Terang and Mortlake Health Service Public

Timboon and District Healthcare Service Public

Western District Health Services Public


Gippsland RICSName

Gippsland RICSHospital type

Bairnsdale Regional Health Service Public

Bass Coast Regional Health Public

Bass Coast Community Health Services Public

Central Gippsland Health Service* Public

Gippsland Southern Health Service Public

Gippsland Lakes Community Health Public

Kooweerup Regional Health Service Public

Latrobe Regional Hospital [Traralgon]* Public

Maryvale Private Hospital Private

Neerim District Health Service Private

Omeo District Health Public

Orbost Regional Health Public

South Gippsland Hospital [Foster] Public

West Gippsland Healthcare Group [Warragul] Public

Yarram and District Health Service Public


Grampians ICSName

Grampians ICSHospital type

Ballan District Health and Care Public

Ballarat Health Services* Public

Ballarat Austin Radiation Oncology Centre Public

Ballarat Community Health Public

Beaufort and Skipton Health Service Public

Central Highlands Primary Care Partnerships Public

Djerriwarrh Health Service [Bacchus Marsh] Public

Dunmunkle Health Services [Murtoa] Public

East Grampians Health Service [Ararat] Public

East Wimmera Health Service Public

Edenhope and District Memorial Hospital Public

East Wimmera Health Service Public

Grampians and Pyrenees Primary Care Partnerships Public

Hepburn Health Services Public

Maryborough District Health Service Public

Rural Northwest Health Public

St John of God Health Care [Ballarat]* Private

Stawell Regional Health Public

University of Ballarat Tertiary

Wimmera Health Care Group* Public

West Wimmera Health Service Public

Wimmera Primary Care Partnerships Public


Hume RICSName

Hume RICSHospital type

Albury Wodonga Health* Public

Albury Wodonga Private Hospital Private

Alexandra District Hospital Public

Alpine Health Public

Beechworth Health Service Public

Benalla and District Memorial Hospital Public

Cobram District Hospital Public

Euroa Health Public

Gateway Community Health Public

Goulburn Valley Health* Public

Kilmore and District Hospital Public

Mansfield District Hospital Public

Murray Valley Private Hospital* Private

Nagambie Hospital Public

Nathalia District Hospital Public

Northeast Health Wangaratta* Public

Numurkah and District Health Service Public

Seymour District Memorial Hospital Public

Shepparton Private Hospital Private

Tallangatta Health Service Public

Upper Murray Health and Community Services Public

Walwa Bush Nursing Centre Public

Wangaratta Private Hospital Private

Yackandandah Bush Nursing Hospital Public

Yarrawonga District Health Service Public

Yea and District Memorial Hospital Public


Loddon Mallee ICSName

Loddon Mallee ICSHospital type

Boort District Hospital Public

Bendigo Health* Public

Castlemaine Health Public

Cohuna District Hospital Public

Echuca Regional Health Public

Heathcote Health Public

Inglewood and District Health Service Public

Kerang District Health Public

Kyabram and District Health Service Public

Kyneton District Health Service Public

Maldon Hospital Public

Mallee Track Health and Community Service Public

Maryborough District Health Service Public

Mildura Base Hospital* Public

Mildura Private Hospital Private

Peter MacCallum Cancer Centre [Bendigo] Public

Robinvale District Health Services Public

Rochester and Elmore District Health Service Public

St John of God Health Private

Swan Hill District Hospital Public


North Eastern MICSName

North Eastern MICSHospital type

Austin Health* Public

Eastern Health* Public

Mercy Hospital for Women* Public

Northern Health* Public

Southern MICSName

Southern MICSHospital type

Alfred Health* Public

Cabrini Health* Private

Peninsula Health* Public

Monash Health* Public

Paediatric Integrated Cancer ServicesName

Paediatric Integrated Cancer ServicesHospital type

Peter MacCallum Cancer Centre* Public

Monash Children’s Hospital* Public

The Royal Children’s Hospital* Public

Western Central MICSName

Western Central MICSHospital type

Melbourne Health* Public

Peter MacCallum Cancer Centre* Public

St Vincent’s Hospital* Public

The Royal Women Hospital* Public

Werribee Mercy Hospital Public

Western Health* Public


Appendix 4: Comparison of Identified MDMs by tumour stream 2006-2014

Appendix 4: Comparison of Identified - MDMs by tumour stream 2006-2014 (source data)

Tumour stream 2006 2008 2010-11 2014Breast 16 20 17 16Central nervous system 2 5 4 8Colorectal 13 14 14 12Endocrine 0 0 4 4Multiple 12 9 5 14Genitourinary 12 11 14 14Gynaecological 5 5 7 6Haematology/lymphoma 9 10 8 14Head and neck 5 10 8 7Lung/thoracic 13 13 14 15Sarcoma 0 0 1 1Skin/melanoma 5 5 3 6Upper GI 11 12 17 13


Hepatoma 0 0 0 5Paediatrics 13 10 5 5

Appendix 5: CanNET MDM Dataset

Please contact the Department of Health & Human Services on (03) 9096 2136 for an accessible copy of Appendix 5: CanNET MDM Dataset


Appendix 6: Staging systems used in MDMS, by tumour stream

Appendix 6: Staging systems used in MDMS, by tumour stream (source data)

Tumour stream AJCC version 6 or 7 (TNM)

Ann Arbor (lymphomas)

Durie-Salmon (Multiple myeloma)

FIGO (gynaecological)

MASAOKA (Thymoma)

RAI (CLL)

Other

Breast 16Central nervous system 4 4

Colorectal 12

Endocrine 4 1

Multiple 14 3 1 2 1 1

Genitourinary 14 1

Gynaecology 1 6Haematology/ lymphoma 1 9 4 5 5Head and neck 7


Tumour stream AJCC version 6 or 7 (TNM)

Ann Arbor (lymphomas)

Durie-Salmon (Multiple myeloma)

FIGO (gynaecological)

MASAOKA (Thymoma)

RAI (CLL)

Other

Lung/thoracic 15

Paediatrics 1 1 4

Sarcoma 1

Skin/melanoma 6

Upper GI 11

Hepatoma 4

Other


Appendix 7: Recommendations from Multidisciplinary team meetings in Victoria – Monitoring progress towards achieving best practice cancer care 2010-11

RecommendationsThe Victorian 2010–11 MDT meeting survey evaluation captured a range of data and information to inform progress against multidisciplinary policy, strategic directions, peer organisations, and previous survey evaluations and recommendations. The following recommendations are made to help drive improvements in the delivery of multidisciplinary care and apply to all ICS.

Characteristics of cancer service MDTs in Victoria

• Further development of MDT meetings may be required for particular tumour streams and regions that have a low number of meetings or limited capacity compared with Victorian cancer incidence.

Patient-centred clinical decision making

• An increase in the proportion of cancer patients presented prospectively for MDT meeting discussion and treatment recommendations is required. This may require criteria for prioritising patient presentation at an MDT meeting, and a change in the frequency and/or length of the meeting to promote prospective discussion. Multiple patient presentations at meetings may be appropriate for some complex cases; however, ICS are encouraged to look at the underlying reasons regarding frequency of patient presentation through local clinical audit.

• Further development of clinical handover processes are required to ensure MDT meeting treatment recommendations are communicated to the patient’s GP and/or referring health service. This may promote enhanced care coordination and patient safety.

• There is a lack of processes to support documentation of patient consent. Further improvement is required to increase the documentation of patient consent across the state.

• Further development of processes to support the use of clinical practice guidelines and/or evidence-based treatment protocols is required to ensure appropriate decision making. One example supported by the Cancer Clinical Network is the use of eviQ Cancer Treatments Online, which is available at www.eviq.org.au.

• An increase in the availability of staging information is required to support appropriate multidisciplinary treatment decision making. Staging is the cornerstone of treatment planning.

• Supportive care needs impact on the compliance and outcome of cancer treatment. Further improvement is required to increase relevant supportive care professional attendance and contribution to MDT meeting discussion.

The multidisciplinary team

• An increase in the attendance of core members relevant to each tumour stream is required. Improvement in membership is required across all disciplines including diagnostics, nursing and allied health.


http://www.eviq.org.au/

Meeting organisation and logistics

• Further development of effective linkages among health service MDT meetings and ICS should promote specialist multidisciplinary treatment planning for regional patients, offer valuable peer support, promote efficiency, and build capacity among the MDT.

• A review of the Victorian Multidisciplinary meeting toolkit resource should be undertaken to enhance MDT meeting resources, templates and tools.

• Further consideration of available MBS funding for MDT meetings is required by health services.

Meeting infrastructure

• Further consideration should be given to implementing meeting management software across MDT meetings. In particular metropolitan ICS should promote the implementation of meeting management software in member organisations. The use of software can promote efficiencies such as rapid documentation of a treatment recommendation plan and/or integration in the patient’s medical record. Software also promotes the collection of clinical data.

A multidisciplinary dataset should be established to promote consistent data collection for monitoring and benchmarking cancer service performance. The collection of cancer patient data could align with existing cancer registries and reporting of cancer clinical indicators.


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